5002 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION'& PERMIT 5002
ADDRESS
0 6!) - LJ�D �R BUILDING—ELECTRICAL—PLUMBING—MECHA C
OWNER'S r` / /� „ - PLAN CIFECK VALIDATION
"AME OTV. ELECTRIC PERMIT FEE y�
. • 6LOHN PHDNESY6 d8G �
C NONTRACTORs UTLETS
AME G�9�
-SWITCHES-RECEP 5.00/1.00 /
NT0'V PDO J-$ LIGHTING FIXTURES 5.00/1.00
NTRASDDRE ACTOR
A - PPLIANCES-RESIDENTIAL 4.00
CO
90d,WMa fd T-K S PH�ON•EK'lI'__7 tV/O
PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ORq ys
EN/\ trS�,,&4 FIT LIC.No. / SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION.
ADRf/ STT'A/c SuurN GRrF-ZIP EMP.METER OR POLE IN 15.00
SS
ADDRESS rs MOTORS SCH. 4
ADDRESS .�r .
17,799-cfi W/AvCJ4E STEIZ SERVICE CHANGE 1 00
D o o LICENSED CONTRACTORS DECLARATION
<u y w I hereby affirm that I am licensed under provisions of Chapter 9 f dIQ, L CE DATE<N (commencing with Section 7000)of Division 3 of the Business and BLDG. PIQ.
r D z Professions Code icense is in full for 'nd Sf t PW
z o'�,- License Class � Lic.Net bar
w t Oma /ae8l, 4 Con acto
a a a ¢ OWNER-BUILDER DECLARATION BU
a a A. " MISC.— REFER TO ORD INFORMATION
wg LL r 1 hereby affirm that I am exempt from the Contractor's License h
aD¢ Law for the following reason. 7031.5,Business and Professions PERMIT ISSUANCE VALUATION S/FT.
N„ s.oD y
Code:Any city or county which requires a permit to construct,alter, O�0
R ¢Q p improve,demolish.or repair any structure,prior n its issuance,also ELEC.CONTR. LIC.NO' To.A q �y
O u requires the applicant for such permit w file a signed statement that TOTA PERMIT TO
w$ he is licensed pursuant to the provisions of the )ofDivision License
rx ¢
Law(Chapter 9lcommencingwith Section 700010(Uivision3ofthe
Business and Professions Code)or that he isexempt therefrom and DTV. PLUMBING PERMIT FEE
ss- D the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to B civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00 AI"T�
of nm more than five hundred dollars(5500)):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contrac(or's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
monis are through his own employees.Provided that such improve-
mnuall0 not intended or employees,red for provided
ed thathowevsuch
ehmlding GAS-EA.SVSTEM-11NC.40UTLETS 4.00
OTAMprovement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or air- . . .
- RES IND LOG PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,the exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law duos not apply -
to tr owner of property who builds tr improves used uand who LAWN SPRINKLERS-O A.) 1.00
confronts for such projects with a contradorls)licensed pursuant to
' the Contractor's License Law. � SEWER-SANITARY-BYOB EA. f /8.00 TRACT NO. PARCEL NO.
❑ [a
exempt under Sec. ,B.&P.C.for Ihis WATER HEATER T 4.00
reason
Date Owner WATER SYSTEM4.00 + ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING059t cupultillo 4.00
I hereby affirm that 1 have a certificate of consent w self-inoue, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,Or a certified
copy thereof(Sec.3800,Lab,C.l. Wlf'E/3.9Lf LB/ OtG 0 0 e_ U -
Policy No. Company ��p�./ - -
Q '❑ Certified copy is hereby furnishtd�-D/ IO E'.Ta]rl� / FIRE SPRINK ENERGY T-24
Z Z Gp Ce, f e�Py filen with the city inspection dvismn. MISC. REFER TO ORD.
O Applicant , X �, 9 Q6a Y❑ N❑ Y ❑ IN
M LO C1 RTI E I CATE OF Ii XEM PTI ON PROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE ,A.L.O.C.
LU > COMPENSATION INSURANCE PLG.CONTR, LIC.NO. PLG. q' / os+
CL O (This section need not be completed if the permit is for one TOTAL CZ9 Y❑ N❑. Y❑ IN
D Z hundred dollars($100)or less.)
L) O 1 certify that in the performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
LL H mi[is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
Q i Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code,you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 10p0011F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE d"
I hereby an that there is a Construction lending agency for EXHAUST HOOD(WITH DUCT) - 2.00
(firt
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name / HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC �d
Lender's Address
—
1 certify that 1 have read this application ad stale that the above VENTILATION FAN (SINGLE) 3.00 y �s
information n correct. I agree to comply with all city and county PLUMBING CX 6
ordinances and state laws relating w building construction. and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to cola upon the BOILER-COMP IGVBr 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,�vosts and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
granting of h IL MECH.CONT. LIC.NO. MECH. '
To
TOTAL
Signature of Applicant/ ontractor Date
OFFICE COPY .